Speech and Swallowing Rehabilitation

After a total laryngectomy (removal of the voice box), people always want to know if they will be able to speak. The answer is yes. There are a few different methods to achieve speech after a total laryngectomy. They all take practice, and you will discover which one is best for you. If you are determined to succeed, you will be surprised at how good your voice can be with some of these methods. You should have a discussion with a speech and language pathologist (SLP) before your larynx removal surgery to discuss your options.

The three main methods of speech after a total laryngectomy are electrolarynx, esophageal speech and tracheoesophageal puncture with prosthesis (TEP).

Electrolarynx

An electrolarynx, also called an artificial larynx, is an easy and affordable way to speak after a total laryngectomy. The electrolarynx creates a vibration when placed on the neck or facial skin. Those vibrations reach the mouth, and the vibrations can be modified by the mouth as if you were speaking. The result is a monotone voice, but one that can be well understood. The more you practice, the better you will become. The disadvantages are that it requires your hands, the voice created is quite mechanical and it requires battery replacement, but the voice can be quite loud and is easy to use.

There are two types of artificial larynx devices. The most common is one that is simply held up against the skin of the neck of face and the vibrations are transmitted intra-orally. The other type of electrolarynx has an attachment that looks like a straw (called an oral tube) that directs the vibrations into your mouth. Vibrations of your natural oral linings can result in speech, or a vibrating palatal prosthesis can result in speech.

Esophageal speech

Esophageal speech is essentially burping out air from the stomach and controlling articulation within the mouth. Air is trapped inside the mouth, swallowed down into the stomach and then burped out. The air vibrates the surfaces of the esophagus and pharynx to create sound.

The advantage of esophageal speech is that it is cost effective, requires no devices or procedures and does not require the use of your hands. The problems are that it is difficult for some people to learn effectively, the voice is often softer and only fairly short sentences can be spoken.

Tracheo-esophageal puncture with prosthesis

This procedure and associated device is one of the best available speech rehabilitation devices. This device is inserted by a surgeon in the office or in the operating room. Better fitting, instructions on how to use it and any required modifications are then done by a speech pathologist in the office setting.

A primary tracheoesophageal puncture (TEP) is one that is done during the same operation as the laryngectomy. A secondary TEP is done at a later date, either in the office or the operating room.

Regardless of whether the TEP is done primarily (immediately after the laryngectomy as part of a single operation) or secondarily (as a separate procedure on a different day), the basic technique is the same. A small hole is made in the back wall of the trachea near the level of where it is sewn to your neck. The hole extends from the back wall of the trachea into the front wall of the esophagus, directly behind the trachea. Once the puncture is created, either a temporary catheter is placed through the puncture site to keep it open, or the prosthesis is placed through the puncture site. If a catheter is placed, then the prosthesis will be inserted in a week or two by a speech therapist in the office giving the puncture tract time to mature.

The TEP prosthesis has a one-way valve that allows air to go from the trachea through the prosthesis into the esophagus, but it prevents liquids and food from moving from the esophagus through the prosthesis into the trachea. If there is leakage in or around the prosthesis, it is probably in need of a change.

TEP speech is created in the following way. You take a breath into your lungs as you normally would through your neck via your trachea. Then, when you breathe out and want to speak, you simply cover the tracheostomy opening in your neck, and all the air passes through the little prosthesis that connects your trachea with the esophagus immediately behind it. Air is forced into the esophagus, up your throat and out your mouth. Mucosa of the esophagus and pharynx vibrate as the air passes through, creating sound.

The disadvantages of a TEP are that the device can be expensive and requires changing every few months. It may become colonized with yeast and will leak from the esophagus into the trachea. It requires hands to occlude the stoma when you want to speak, though there are some additional devices that allow for hand-free use of the TEP device.

The speech created by a TEP device, with the right amount of guidance from an experienced SLP and with your practice, can be very clear and improves with time.

Helpful hints for dealing with a tracheo-esophageal prosthesis

Keeping it clean: Depending on the type you have, your prosthesis should have come with either a brush to insert into the prosthesis or a flushing device to inject water into and through the prosthesis to clean it. For either technique, the prosthesis should be cleaned while in place in the fistula tract about twice a day. This will ensure that you can produce clear, continuous voice.

Dealing with leakage: If you notice that you are coughing after drinking liquids, or foods or liquids are coming out through your prosthesis, this indicates that your prosthesis is wearing out and needs replacing. You should contact your speech pathologist immediately to set up an appointment for replacement. If you have the type that you can change yourself, you should exchange it for a new prosthesis. The prosthesis can be sealed at the outer end with a specially designed plug. This will prevent leakage during meals, but this is just a stop-gap measure until you can have your prosthesis replaced.

Fungal infection: Sometimes plaque and a fungal film (biofilm) develops on the inner collar of the prosthesis that sits in the esophagus. You can obtain a prescription from your physician for Nystatin or some other anti-fungal medicine that you can swish and swallow to prevent plaque from developing.

If the prosthesis falls out: If the TEP falls out, it is imperative that it be quickly replaced or that a small tube is inserted inside the puncture site immediately before it closes up (a few hours) until you can see your speech and language pathologist. If you are not comfortable placing something inside the puncture site yourself, and your SLP or head and neck doctor is not available, you should go to an emergency room and have it placed by a doctor. Any type of a small catheter or tube will work to keep the hole from closing up and avoiding a second surgery to create a new puncture. Also, make sure you know where the fallen prosthesis is—this way your doctors can be certain it hasn’t fallen into your lungs.